Appeal a declined critical illness claim
Why are Critical Illness Insurance claims rejected?
Thankfully, every year, thousands of critical illness claims are successfully paid out by insurers, but unfortunately, lots of claims are declined.
Insurers refuse to pay out on critical illness claims for many reasons. In our experience, the top three reasons insurers do not pay critical illness claims are:
Your illness doesn’t meet the insurers definition of ‘severity’, your condition isn’t covered by the policy terms and conditions and the insurer says you didn’t tell them something about your health or lifestyle when you took the policy out. Let’s take a closer look at each reason.
1. Your illness doesn’t meet the insurers definition of ‘severity’.
Some illnesses may only be covered if they meet a certain level of seriousness—such as strokes that result in lasting neurological damage or more advanced stages of cancer.
Critical illness insurance typically covers a range of cancers, but the specifics can vary between policies. Generally, insurers cover cancers that are considered life-threatening or have reached a certain stage. Early-stage cancers, pre-cancerous conditions, and some skin cancers may not be included. For example, prostate cancer is often only covered if it has reached a specific stage—typically T2b N0 M0 or higher. Similarly, common skin cancers like basal cell carcinoma or squamous cell carcinoma may not be covered unless they meet defined criteria.
If your critical illness insurance claim is refused because your illness doesn’t meet the insurers definition of severity, it is definitely worth speaking to us. More times than not, insurance companies make the right decisions, but sometimes they don’t. Our team has experience of appealing and successfully overturning these decisions.
2. Your condition isn’t covered by the policy terms and conditions
Each insurer has their own list of illnesses they cover, which will be detailed in your policy documents. Commonly covered illnesses include some types of cancer, heart attacks, strokes, and conditions like Multiple Sclerosis.
Usually, insurers make the right decision when declining claims for this reason, however, sometimes they don’t. Particularly if your condition is rare or if the medical evidence your doctors submitted was disputed by the insurance company, it is definitely worth speaking to us. Our team has experience of successfully overturning these decisions.
3. The insurer says you didn’t tell them something about your health or lifestyle when you took the policy out
This is referred to as non-disclosure which is a type of misrepresentation; you can find out more about this on our non-disclosure and misrepresentation page.
Again, this is an area that our team at Appeal Avenue have much experience of appealing and successfully overturning, so it’s certainly worth speaking to us if your insurance claim has been refused for this reason.
What do I do if my critical illness claim is declined?
Let Appeal Avenue handle your claim process for you
Appeal Avenue, specialise in supporting people who’ve had critical illness claims rejected.
On our first call, we will talk to you about your situation, this will include questions about your diagnosis and health. Our team will also listen to your side of the story. If you’re happy for us to act on your behalf, we would then look at your policy terms, your medical records, and how your insurer reached their decision. If we believe the decision may be incorrect, we’ll form a complaint or appeal for you.
Appeal Avenue can advocate on your behalf through every aspect of the declined insurance claim appeals process, giving you the time and space to concentrate on your health and wellbeing.
Using our vast knowledge and experience of this very niche and complex area, we can write every letter, speak with your insurer and medical professionals, ensuring that your complaint or appeal is presented in the best way possible. Rest assured your insurance appeal is in safe hands with Appeal Avenue.
We offer a no win, no fee advocacy service where we can handle the appeal on your behalf. You’ll only pay if we’re successful.
Make your own complaint or appeal following our guide below
If you would prefer to submit your own complaint or appeal, follow the process below. We are here, if you find this process overwhelming, or if you need any support.
1. What are the insurer’s reasons for declining your claim?
Ask your insurer to explain their reason for refusing your claim in writing. Work through this letter in a logical way- if you don’t agree with what they have said, make notes, so you can come back to it later.
2. Gather evidence for your appeal.
Depending on the reason for your insurer’s decision, it might be a good idea to gather evidence that contradicts what they are saying. This might involve looking at your medical records or obtaining confirmation and clarification from your doctors.
3. Write your complaint.
– We would always suggest making your complaint in writing, this gives you the opportunity and time to plan, consider and reflect on what you want to say.
– Try to be as logical as possible and refer to the points that the insurer has made in their decline letter.
– Include a timeline of what has happened and put the date you send the letter of complaint at the top.
– Try to remain calm and professional- you don’t want to detract from the complaint.
– Reference the evidence you have gathered that contradicts what the insurer has said.
– Always focus on what your policy terms and conditions say.
– Make it clear what you are looking for as an outcome to your complaint.
4. Wait
Your insurer should send you an acknowledgement within a couple of weeks to let you know they have received your complaint and are investigating it- if you don’t receive this acknowledgement, you should contact your insurance company to make sure they received your letter.
The insurer has 8 weeks to investigate your complaint.
5. Response
Your insurer will respond to your complaint in writing.
If they ‘uphold’ your complaint (which means that they agree there has been a mistake) they will tell you what they plan to do to put things right.
If they don’t uphold your complaint (they still disagree), they will tell you why. They will also tell you what you can do next if you wish to pursue the complaint further.
6. Escalate your complaint to the Financial Ombudsman Service
If your insurer did not uphold your complaint and you are still unhappy with their decision, the next step is to take it to the Financial Ombudsman Service.
The Financial Ombudsman Service is there to independently review your complaint. They will consider the facts of what has happened and will listen to yours and the insurers opinions. They will then give an unbiased decision on what should happen next.
There are two ‘tiers’ within the Financial Ombudsman Service. Your complaint will firstly be reviewed by an ‘Investigator’ who will consider the facts of the case and issue their viewpoint.
If you, or the insurer, disagrees with the Investigators decision, you can ask for it to be reviewed by an Ombudsman. The Ombudsman will independently review the facts of the case and will issue their ruling. The Ombudsman’s decision is binding on the insurer.
If you disagree with the Ombudsman’s decision, the next step would be to seek legal advice from a qualified solicitor.
Ready to get started?
Start a new claim or get help with your appeal for declined critical illness insurance today.